Distal Femoral Fractures

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Open Fracture Management
P. Blachut Division of Ortho Trauma Vancouver
General Hospital University of British Columbia
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• Introduction
• Assessment
• Classification
• Management

Open fractures
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Goals of Fracture Management

• Fracture healing with satisfactory length and
  alignment
• Avoidance of complications
• infection
• nonunion
• malunion
• stiffness
• Early restoration of function

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Fracture Healing

• Biologic factors
• Biomechanical factor

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Avoidance of Complications (Infection)

• No necrotic tissue
• No dead space
• No contamination
• Well vascularized tissue

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Early Restoration of Function

• Early mobilization
• Stable fixation
• Early wound healing
• Avoid excessive scarring
• Early wound coverage with quality tissue
• Preservation of critical tissues
• Nerves
• Tendons

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Therefore

• The soft tissues are paramount to the successful
  management of fractures

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• A bone healing complication with good soft
  tissues is easier to deal with than a
  complication with poor soft tissues

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Consequences of an Associated Soft Tissue Injury

• healing potential
• resistance to infection
• contamination

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Assessment

• Look for associated life threatening injuries!!!
• Carefully assess and document neurovascular status

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ATLS (Advanced Trauma Life Support)

• Primary Survey
• A irway
• B reathing
• C irculation
• D isability
• E xposure
• Secondary Survey

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Compartment Syndrome

• Always look for in fractures with soft tissue
  injuries
• Open fractures - up to 10 have compartment
  syndrome

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Amputation vs. Salvage

• Multidisciplinary decision
• Based on the assessment of likely ultimate
  function of limb compared to function with
  amputation

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Factors Favoring Amputation

• Warm ischemia time gt 8 hrs
• Severe crush
• minimal remaining functional tissue
• Chronic debilitating disease
• Severe polytrauma
• Mass casualty
• complexity of reconstruction

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Classification
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Classification - Open Fractures

• Reflection of amount of energy imparted and
  consequently, the prognosis
• Skin wound size
• Level of contamination
• Extent of soft tissue injury/ periosteal
  stripping
• Fracture configuration

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Classification - Open Fractures

• Classification can really only be done at the
  completion of debridement

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Classification - Open Fractures

• Open injuries
• Gustilo Anderson
• AO

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Open Fracture - Gustilo Classification

• Type I
• Small wound
• Inside out
• No/minimal contamination
• Minimal soft tissue trauma
• Low energy fracture pattern

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Open Fracture - Gustilo Classification

• Type II
• Moderate wound
• Some contamination
• Some muscle damage
• Moderate energy fracture pattern

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Open Fracture - Gustilo Classification

• Type III
• Large wound
• Significant comtamination
• Major soft tissue trauma
• crushing
• periosteal stripping
• High energy fracture pattern

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Open Fracture - Gustilo Classification

• IIIA
• enough soft tissue to cover bone
• IIIB
• insufficient soft tissue
• need flap (local, free)
• IIIC
• vascular injury requiring repair

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Open Fracture - Gustilo Classification

• Type III - Additional Factors
• Barnyard
• Shotgun
• High velocity gunshot
• Displaced segmental fracture
• Neglected open fracture (gt 8 hrs)
• Bone loss

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Management

• First aid
• Emergency Room
• Definitive
• Rehabilitation

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First Aid

• Control bleeding
• direct pressure
• Realign
• further soft tissue damage/ compromise
• Splint
• comfort
• further damage

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Emergency

• First aid if not already given
• Remove gross debris/irrigate/dress/ splint
• Tetanus prophylaxis - if necessary
• Antibiotics

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Emergency

• The open wound should be assessed and documented
  only once

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Antibiotics

• ? Prophylactic vs. treatment
• Closed with operative Rx Cephalosporin
• Grade I
• Grade II / III Add aminoglycoside
• High Risk Add penicillin

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Antibiotics

• Antibiotics can not compensate for an inadequate
  surgical management

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Timing of Administration of Antibiotics

• The Prevention of Infection in Open Fractures An
  Experimental Study of the Effect of Antibiotic
  Therapy
• Worlock, et al JBJS 1988

No antibiotics 1-4 hrs post-inoculation 1 hr.
pre-inoculation
91 infection 51 infection 30 infection
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Antibiotics

• The Role of Antibiotics in the Management of Open
  Fractures
• Patzakis, et al JBJS, 1974

Control Pen./Streptomycin Cephalothin
13.9 infection 9.7 infection 2.3 infection
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Definitive Treatment

• Wound excision
• Wound extension
• Debridement
• Irrigation
• Bone stabilization
• Wound dressing
• /- re-debridement
• Early wound closure/coverage

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Timing of Operative Intervention

• General standard - within 6-8 hours
• Not evidence based!!

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Operating Room

• Scrub/remove gross debris/ irrigate
• Double setup
• debridement/irrigation
• bone stabilization if internal fixation planned
• Tourniquet
• apply/not inflated
• in case of bleeding

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Wound Excision

• Excise crushed/ contaminated skin edge

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Wound Extension

• Sufficient extension to fully evaluate and treat
  soft tissue injury (approximately 1 diameter of
  limb)
• Anticipate incisions for bony stablization/soft
  tissue reconstruction
• Avoid incision that will compromise skin further

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Wound Extension
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Debridement

• Layer by layer
• Remove all devitalized and contaminated tissue
  (including bone)

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Debridement - Objective

• To leave a wound with
• No/minimal contamination
• Well vascularized tissue for healing and to
  resist infection

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Debridement

• When in doubt, take it out

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Irrigation

• 10 litres for significant wounds
• saline
• ? antibiotics
• ? pulsed lavage
• ? detergent

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Irrigation

• Improves visualization
• Float out necrotic tissue
• Flush out debris
• Reduce bacterial population

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Irrigation

• The solution to pollution is dilution

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Stabilization
The Prevention of Infection in Open Fractures
An Experimental Study of the Effect of Fracture
Stability Worlock, et al Injury 1994
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Bony Stabilization

• Second prep if internal fixation
• Principles
• Minimize further trauma
• Sufficient stability to allow early rehab
• Should not impede subsequent soft tissue
  management
• Restoration of anatomy

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Bony Stabilization

• Diaphyseal Fractures
• Humerus
• Forearm
• Femur
• Tibia

ORIF IM nail
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Bony Stabilization

• Articular Fractures
• primary ORIF
• spanning external fixator
• / - articular ORIF
• ? delayed ORIF
• external fixation

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Open Wound Management

• Can close extensions
• Occasionally close open wound primarily
• No crush
• No contamination
• Small wound
• No dead space
• Closure without tension
• Keep wound moist - ? bead pouch

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Open Wound Management
Price of Primary Open Wound Closure Gas
Gangrene Limb Loss Death
? leave open
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Open Wound Management

• Antibiotic beads
• Depo of local
• antibiotics
• ? efficacy
• ? toxicity

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Antibiotic Bead Pouch VGH Experience

• 85 open tibial shaft fractures
• 59 antibiotic bead pouch
• 26 no bead pouch
• No statistical difference in
• age, sex, ISS, time to wound coverage

Keating, et al
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Antibiotic Bead Pouch VGH Experience

• Infection

Type II Type III TOTAL
No Bead Pouch Bead Pouch p value
16 0 lt0.03
11 3 0.35
15 2 lt0.06
Keating, et al
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Redebridement

• High grade injury
• Severe contamination
• Questionable tissue viability
• ? adequacy of debridement
• Q 24-48 hours until wound is viable

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Wound Closure/Coverage

• ? Immediate
• Optimally by 3-7 days
• Principles
• Durable coverage
• Well vascularized
• soft tissue envelope
• for bone
• Fill dead space

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Wound Closure/Coverage

• Secondary intent
• Delayed primary closure
• Skin graft
• Flap
• local
• distant - free

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Wound Closure/Coverage
Role of VAC yet to be delineated
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Rehabilitation

• Splint joints in functional position pending soft
  tissue healing
• Swelling control
• ROM/Muscle rehabilitation as soon as wound
  healing permits
• Wound management to minimize scarring

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Summary

• The soft tissues are critical to the successful
  management of all fractures

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Summary

• Aggressive, systematic management is required for
  fractures with significant soft tissue injuries

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THANK YOU !!
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ARS

• 31 yr old man
• Ped struck
• Isolated injury

• The most critical component
• of this mans treatment is
• Antibiotics
• Tibial fixation
• Avoidance of reaming
• Soft tissue management
• Early fracture stabilization

Open fractures
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ARS

• 31 yr old man
• Ped struck
• Isolated injury

• After management of the soft
• tissues the bone is best
• stabilized by
• Cast
• External fixator
• Plate
• Reamed IM nail
• Unreamed IM nail

Open fractures
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ARS

• 31 yr old man
• Ped struck
• Isolated injury

• How would you grade this
• injury?
• I
• II
• III A
• III B
• III C

Open fractures
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ARS

• 31 yr old man
• Ped struck
• Isolated injury

• The most critical component
• of this mans treatment is
• Antibiotics
• Tibial fixation
• Avoidance of reaming
• Soft tissue management
• Early fracture stabilization

Open fractures
69
ARS

• 31 yr old man
• Ped struck
• Isolated injury

• After management of the soft
• tissues the bone is best
• stabilized by
• Cast
• External fixator
• Plate
• Reamed IM nail
• Unreamed IM nail

Open fractures